Massive Transfusion Protocol
Reviewed and revised 10 March 2014
OVERVIEW
Massive transfusion is defined as
- replacement of >1 blood volume in 24 hours, or
- >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg), or
- in children: transfusion of >40 mL/kg (blood volume in children over 1 month old is approximately 80 mL/kg)
A Massive Transfusion Protocol should be used in critically bleeding patients anticipated to require massive transfusion
GOALS IN MANAGEMENT OF MASSIVE TRANSFUSION
- early recognition of blood loss
- maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (Hb)
- arrest of bleeding in combination with use of early surgical or radiological intervention, and
- judicious use of blood component therapy to correct coagulopathy
THERAPY INDICATIONS IN MASSIVE TRANSFUSION
- Check these parameters early and frequently (e.g. every 30-60 minutes while massive transfusion is ongoing)
| Parameters | Values to aim for |
| Temperature | >35 °C |
| Acid-base status | pH >7.2, base excess <–6, lactate <4 mmol/L |
| Ionised calcium (Ca) | >1.1 mmol/L |
| Haemoglobin (Hb) | This should not be used alone as transfusion trigger; and, should be interpreted in context with haemodynamic status, organ & tissue perfusion. |
| Platelet (Plt) | ≥ 50 x 10^9 /L (>100 x 10^9 if head injury/ intracranial haemorrhage) |
| PT/APTT | ≤ 1.5x of normal |
| Fibrinogen | ≥ 1.0 g/L |
MASSIVE TRANSFUSION PROTOCOL TEMPLATE
PROBLEMS WITH MASSIVE TRANSFUSION
Risks and complications of large volume resuscitation with blood products
- volume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
- over-transfusion (monitor Hb regularly, titrate according to needs)
- hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
- dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
- Transfusion related acute lung injury (consider use of filters, leukodepletion)
- excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
- hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
- disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)
If uncross-matched / O neg blood
- Haemolytic disease of newborn if RhD mismatch
- Difficulty with cross-matching future blood product
- Difficulty with matching solid organs
Logistical issues
- distractions resulting in not controlling source of haemorrhage, and
- risks of hurried cross-checking and incompatibility (allocation of sufficient resources and personnel, standard programs in place to facilitate process and anticipate needs)
- other problems including loss of identity, crossmatching issues, loss of baseline haematological information etc)
Usual transfusion reactions and problems
- TRALI / TACO
- Acute / delayed haemolytic transfusion reaction
- Non-febrile haemolytic transfusion reaction
- Bacterial / viral infection
- Anaphylaxis if IgA deficient
- GVHD
- Storage lesion effects
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
CCC Transfusion Series
Blood Products: Cryoprecipitate, Fresh Frozen Plasma (FFP), Platelets, Red Cells (RBCs)
>>> Factor Concentrates: Prothrombinex, Factor VIIa, Fibrinogen Concentrate
Reversal Agents:
>>> Rivaroxaban / Apixaban / Enoxaparin: Andexanet Alfa, Rivaroxaban and Bleeding
>>> Dabigatran: Idarucuzimab, Dabigatran and bleeding
>>> Heparin: Protamine
>>> Warfarin: Vitamin K, FFP, PTx, Warfarin Refersal, Warfarin Toxicity
Testing: Coagulation Studies, TEG / ROTEM (Thromboelastography), Platelet function assays
Conditions: Acute Coagulopathy of Trauma, Disseminated Intravascular Coagulation (DIC), Massive Blood Loss
General Topics: Blood Bank, Blood Conservation Strategies, Blood Product Compatibilities, Blood Transfusion Risks, Massive Transfusion Protocol (MTP), Modifications to Blood Components, Procedures and Coagulopathy, Storage Lesions, TRALI, Transfusion Literature, Transfusion Reactions
References
- National Blood Authority. Patient Blood Management Guidelines: Module 1 – Critical Bleeding/Massive Transfusion.[cited 2011 Jun 30]. Available from: http://www.nba.gov.au.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
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from the mathematical point of view “base excess <–6” is -7
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